Triple Taxon Test/Technique: An Innovative Method for Self-Learning and Self-Evaluation in Health Problems

Abstract

To manage a patient, physicians, and medical students need to collect the patient’s data and information in different ways, evaluate, interpret, analyze clinical reasoning, and, after diagnosis, take action to solve the patient’s problem. For this purpose, they must pass at least three summarized categories of the cognition domain. These three categories include: remembering, interpretation, and problem-solving. In this article, we intend to introduce an innovative case-based practice or test technique to our audiences, which includes all three above-mentioned categories. We have named this method TTT (Triple Taxonomy Tests/technique) or MTQ (Mixed Taxonomy Questions). This form of case-based test/technique is applicable in self-learning, self-assessment, or official evaluations, which is explained below in the form of an example.

1. Introduction

Psychologists have divided educational fields into three categories, including “cognitive,” “emotional,” and “psychomotor” domains. Benjamin Bloom has classified the field of cognition from the lowest level (remembering) to the highest level (evaluation and creation) [1, 2].

Medical sciences teachers must use higher levels of these three domains to improve the quality of students’ learning and not be limited only to the lower levels, particularly in the cognitive domain. The quality of learning of medical students may decline without targeting higher cognitive levelsof abilities such as evaluation, interpretation, analysis, reasoning, and creation [3]. Therefore, medical students are expected to learn such high-level cognitive skills [4], and acquiring these abilities is vital for their future performance [3].

The importance of active involvement of medical students in clinical issues is generally accepted by medical education experts for improving the quality of learning, and various methods are used to achieve this goal. Understanding this need has led medical schools to adopt and implement some degrees of integration of basic and clinical sciences (vertical integration). The use of clinical cases to help teaching, which is called case-based learning (CBL), is one of the most interesting strategies in this field, and different types of implementations of this method have been described [5, 6].

On the other hand, lifelong learning skills, including self-learning and self-assessment, are also among the most important strategies accepted in adult education and vital for the professional development of doctors. Case-based questions are one of the useful tools that can be used in the field of self-learning and self-evaluation by students in the teaching and learning process [7, 8].

Also, one of the important components of the educational process is measuring the educational progress of learners and evaluating their quality of learning. Several research have been conducted about the quality of exams held in universities and higher education institutions. The results of many of these studies have shown that many teachers enter the field of teaching without getting enough training in measuring methods and designing tests. As well as, most of the findings of these studies have shown that the teachers, to measure students’ academic progress, often emphasize superficial and simple concepts, and many times, the questions are ambiguous and are not purposeful [9].

The results of Josefowicz’s study showed that teachers spent a lot of time preparing course materials, but they did not spend much time designing exam questions, and their knowledge of evaluation principles and exam question design techniques was insufficient [10]. The available evidence shows that training faculty members and giving them appropriate feedback have improved the quality of exam questions, especially multiple-choice questions, and improved student evaluation conditions [11].

To improve the quality of students’ learning and encourage them to think and act at different levels of the cognitive domain, we have invented a new case-based method, which we introduce in this present article.

The purpose of this article is to encourage students to make logical use of what they have learned, practice, and strengthen the ability to interpret, analyze, criticize, clinically reason, diagnose, and solve patients’ problems.

2. Introducing TTT (triple taxonomy test/technique)

Three-level case-based questions or TTT (Triple Taxon Test/Technique) and dual-purpose questions are designed questions in the field of patient management, and medical students can use them for self-study and self-evaluation to strengthen their professional capabilities in three categories of “remembering”, “interpretation and reasoning,” and “olvingsroblem-p”. On this occasion, we intend to present one of these cases to the audience to get familiar with this technique or test.

3. Case features

• They are placement test questions.

• They are case-based and practical questions.

• They include the taxonomies of recall, interpretation, and problem-solving.

• They contain a trunk with several blank spaces.

• They contain several characteristic, contradictory, or unrelated options.

• The score of each space is one, and the value coefficient of the questions is the same.

• Students will receive a lot of information in the feedback of these questions.

4. How to design a case

• We choose a real case, among the numerous interesting clinical cases.

• We specify the questions in three categories of recall, interpretation, and problem-solving.

• Inside the case, we remove the keywords and replace them with blank spaces.

• In the remembering section, we use options that the examinee can only use his / her memory to select those options.

• In the interpretation section, we use options whose selection requires interpretation, reasoning, calculation, analysis, comparison, use of standards (cut-off points), and diagnosis.

• And in the decision-making and problem-solving section, we choose options that are helpful for diagnosis and treatment, development, judgment, selection, and problem-solving.

• We arrange the options under the case description.

• It should be noted that for each answer option, there must be a valid reference.

• Among the options, we have also included the correct option (the main answer to the question), prepositions, and contradictory words.

• The feedback section to the students is completed with the instructor’s explanations and using authentic sources.

5. Introducing an example of TTT cases

This article presents an innovative case-based method for better learning for medical students. With this method, it is possible to design tens, hundreds, and thousands of cases of common diseases. In this case, our main contacts are medical interns, faculty members, and assistants in internal medicine, infectious diseases, social and family medicine, pediatrics, adult and child psychiatry, adult and child neurology, clinical psychology, health psychology, and medical education.

6. Notice to the audience

Dear audience, please first read the case carefully and fill in the blanks using the options below, give yourself a grade, then by reading the answers, assess your abilities in the three areas of “remembering,” “reasoning and interpretation,” and “problem-solving.” (The maximum score in this case is 16).

7. Case presentation

In the interval between the two national days of the Polio Mass Vaccination plan to eradicate polio, in 1994 AD (equal to 1373s), in Ahmedabad village, Ardakan township, Yazd province, in Iran, a sudden incident occurred with paralysis in the upper limbs of two 12- and 13-year-old girls of a middle school. Then, within a week, the disease spread to 15 other students of the same school, all of whom were 12 years old. At the same time, four other students who were 9 years old from an elementary school near the first high school were diagnosed with upper limb paralysis. (A total of 21 students).

The onset of the disease was at the same time as national and regional advertisements about the necessity of vaccination against polio and explaining the consequences of lack of vaccination among people. National days were held in the months of April and May (near the final exams of the students) [12].

Immediately after confirming the ……………….., among these students, all of them were evaluated separately by specialized medical teams, including pediatricians, infectious disease experts, neurologists, and psychologists. The schools were temporarily closed. The village environment and schools were also evaluated by environmental health experts and entomologists, and the necessary measures were taken.

The socioeconomic status of the affected girls was low to medium, and the average family size was six people; the occupation of most of the household heads was agriculture and animal husbandry. The ……………….. was a 13-year-old girl, taller than her classmates, who had failed in the last class for 1 year.

According to the records, vaccination of all affected girls except one of them was complete against diseases, especially poliomyelitis. The signs and symptoms of the disease in the vast majority of patients were in the form of paralysis of the right upper limb (except for one of the girls who was left-handed, and her left hand was paralyzed); pain in the joints of fingers, wrists, and elbows; and muscle pain during passive movements of the limb. All of them had disturbances of sensation, touch, heat, itching, and marked paresthesia in the affected limb, and in most cases, there was also headache and anorexia.

In clinical examinations, the patients did not have a fever or skin lesions, the reflexes of the organs were relatively normal, and, psychologically, they were very anxious, and some of them had a history of stuttering, anxiety, nightmare, feeling homesickness, depression, and sleep disorders, and the symptoms were reduced or disappeared with a brief dictation (to suggest).

No special problems were found in environmental health inspections. And there was found in entomological assessments of the schools, houses, animal shelters, etc. A significant number of ………………………… that this indicated the possibility of tick paralysis.

According to the obtained data and information, specialists suggested ……………….., ……………….., ……………….., epidemic polyarthritis (Ross river fever), clinical features caused by arboviruses, and psychiatric disorders such as ……………….. for the patients, and they requested the necessary diagnostic tests for the main diagnosis.

In the performed tests, blood cell count, sedimentation rate, CRP, liver function tests, peripheral blood smear for Borrelia Burgdorferi spirochetes, urine analysis, polio screening tests, electrodiagnostic tests, and joint proceedings were all normal.

Without any action, by temporarily closing schools, during the summer, all the girls recovered, and the wave of the disease subsided, and the patients were only monitored. With the arrival of October and the reopening of schools, the disease among several middle school girls (including the index case) recurred. To solve this problem, experts suggested ………………………..

The points that did not confirm the existence of an organic communicable disease, especially poliomyelitis, were:

The completeness of the vaccination of most of the affected girls against polio; the rarity of ……………….. and ……………….. in polio; the absence of infection in the community, especially among family members; lack of skin lesions caused by insect bites, especially ticks; and the absence of ticks on any part of the body of the affected students. Absence of arthritis in the majority of sufferers (among the sufferers, joint problems were mostly in the form of arthralgia, except for two cases who also had mild arthritis); lack of ……………….. appearance on the skin, which is a characteristic sign for Lyme disease, absence of fever; maculopapular rashes; and bilateral arthritis; which all rule out the disease of ……………….. and the absence of any evidence of organic diseases, especially infections in the performed para-clinical tests.

The points that confirmed the existence of mass hysteria consisted of:

The patients rewe female (mass hysteria is more common in females). This disorder is more common in ………………………… societies, and sufferers of this disorder ………………

The character of the case index is of interest and attraction to the others, and she dominates her peers intellectually, and she is a role model for her classmates and causes ………………... The dominant hand of all sufferers indicates a symbolic connection. The existence of ……………….. advertisements against polio and, at the same time, the stress of end-of-year exams are also effective factors, and finally, the recovery of those affected after being encouraged to compete in volleyball as a team is a determining factor [12]. Score: 16.

Options: endemic - epidemic - outbreak- cluster- health problem - Primary case - Index case- mosquitos - mites - hard tick Ixodes scapularis - bedbugs - Poliomyelitis - Tick paralysis - Mosquito bite arthralgia - Bedbug bite syndrome - Lead poisoning - mass hysteria - Lyme disease - Conducting a course of physiotherapy - prescribing corticosteroids - organizing a movement competition such as volleyball - closing school - paresthesia - Motor reflex disorder - sensory disorder - Bull’s eye - petechial - infectious arthritis - Ross river fever - animal husbandry jobs – a high socioeconomic level more than the community where they live - low to medium socioeconomic level - pre-puberty - think logically - have high self-esteem - are very suggestible - assimilation - bad education caused by - stress caused by.

8. Answers to case questions

8.1 Please check your answers once again before viewing the answers

In the interval between the two national days of the Polio Mass Vaccination plan to eradicate polio, in 1994 AD (equal to 1373s), in Ahmedabad village, Ardakan township, Yazd province, in Iran, a sudden incident occurred with paralysis in the upper limbs of two 12- and 13-year-old girls of a middle school. Then, within a week, the disease spread to 15 other students of the same school, all of whom were 12 years old. At the same time, four other students who were 9 years old from an elementary school near the first high school were diagnosed with upper limb paralysis. (A total of 21 students).

The onset of the disease was at the same time as national and regional advertisements about the necessity of vaccination against polio and explaining the consequences of lack of vaccination among people. National days were held in the months of April and May (near the final exams of the students) [12].

Immediately after confirming the health problem among these students, all of them were evaluated separately by specialized medical teams, including pediatricians, infectious disease experts, neurologists, and psychologists. The schools were temporarily closed. The village environment and schools were also evaluated by environmental health experts and entomologists, and the necessary measures were taken.

The socioeconomic status of the affected girls was low to medium, and the average family size was six people, the occupation of most of the household heads was agriculture and animal husbandry. The index case was a 13-year-old girl, taller than her classmates, who had failed in the last class for a year.

According to the records, vaccination of all affected girls except one of them was complete against diseases, especially poliomyelitis. The signs and symptoms of the disease in the vast majority of patients were in the form of paralysis of the right upper limb (except for one of the girls who was left-handed, and her left hand was paralyzed); pain in the joints of fingers, wrists, and elbow; and muscle pain during passive movements of the limb. All of them had disturbances of sensation, touch, heat, itching, and marked paresthesia in the affected limb, and in most cases, there was also headache and anorexia.

In clinical examinations, the patients did not have a fever or skin lesions, the reflexes of the organs were relatively normal, and psychologically, they were very anxious, and some of them hada history of stuttering, anxiety, nightmare, feeling homesickness, depression, and sleep disorders, and the symptoms were reduced or disappeared with a brief dictation (to suggest).

No special problems were found in environmental health inspections. And there was found in entomological assessments of the schools, houses, animal shelters, etc. A significant number of hard tick Ixodes scapularis indicated the possibility of tick paralysis.

According to the obtained data and information, specialists suggested Poliomyelitis, Tick paralysis, Lyme disease, epidemic polyarthritis (Ross river fever), clinical features caused by arboviruses, and psychiatric disorders such as mass hysteria for the patients, and they requested the necessary diagnostic tests for the main diagnosis.

In the performed tests, blood cell count, sedimentation rate, CRP, liver function tests, peripheral blood smear for Borrelia Burgdorferi spirochetes, urine analysis, polio screening tests, electrodiagnostic tests, and joint proceedings were all normal.

Without any action, temporarily closing schools, during the summer, all the girls recovered, and the wave of the disease subsided, and the patients were only monitored. With the arrival of October and the reopening of schools, the disease among several middle school girls (including the index case) recurred. To solve this problem, experts suggested organizing a movement competition such as volleyball.

The points that did not confirm the existence of an organic communicable disease, especially poliomyelitis, were:

The completeness of the vaccination of most of the affected girls against polio; the rarity of paresthesia and sensory disorder in polio; the absence of infection in the community, especially among family members; lack of skin lesions caused by insect bites, especially ticks; and the absence of ticks on any part of the body of the affected students. Absence of arthritis in the majority of sufferers (among the sufferers, joint problems were mostly in the form of arthralgia, except for two cases who also had mild arthritis), lack of Bull’s-eye appearance on the skin, which is a characteristic sign for Lyme disease, absence of fever, macule popular rashes, and bilateral arthritis, which all rule out the disease of Ross River Fever and the absence of any evidence of organic diseases, especially infections in the performed para-clinical tests.

The points that confirmed the existence of mass hysteria consisted of:

The patients rewe female (mass hysteria is more common in females). This disorder is more common in low to medium socioeconomic level societies, and sufferers of this disorder are very suggestible.

The character of the case index is of interest and attraction to the others, and she dominates her peers intellectually, and she is a role model for her classmates and causes assimilation. The dominant hand of all sufferers indicates a symbolic connection. The existence of stress caused by advertisements against polio and, at the same time, the stress of end-of-year exams are also effective factors, and finally, the recovery of those affected after being encouraged to compete in volleyball as a team is a determining factor [12]. Score: 16.

9. Discussion/feedback

Here we discuss the above case, in the Remembering, Interpretation, and Problem-solving domains. Here, after the students have thought about the case in the allotted time, we give them feedback in the above three areas.

9.1 Remembering

• What do you know about Mass Vaccination Polio in Iran?

  In 1988, the World Health Organization (WHO) suggested the strategy of mass vaccination to countries on national days [13]. The first efforts to eradicate polio in Iran started in the 1950s, but it did not succeed because it was not accompanied by universal vaccination. This problem continued, and it took victims especially in remote border towns and villages until an important incident happened inthe 1373s. Basij volunteer forces, with the help of the Ministry of Health, did important work with coordinated action [14].

  More than 320,000 Basij volunteers vaccinated about nine million children under the age of five all over Iran against polio in just one day. In this project, the Basij parties formed more than 175,000 relief groups (auxiliary groups) in 16,000 vaccination centers, and eventually polio was eradicated in Iran. The effect of the work was so surprising that, in the same year, a letter was written to the President of Iran by UNISE, who was thanked for this important action. In this letter, it was mentioned that “Iran is the only country in the world where health indicators were improved during the war and there were no deaths caused by infectious diseases.” Fortunately, polio has been eradicated in Iran since 1374 [14].

• In the above case, was the 13 year- year old girl an index case or a primary case? What is the difference between these two terms?

  An index case is the first patient identified and reported by health authorities, and a primary case is a person who brings the disease to the community, school, another person, or even the country, and in most cases, it remains unknown [15]. So, the 13–year-old girl, for the first time, before performing any interventions is the index case.

• What are the differential diagnoses of paralysis?

  Poliomyelitis, tick-borne paralysis, Lyme disease, Ross River disease, Hysteria, and so on.

• What is the cause of tick-borne paralysis?

  Ixodes scapularis blood-sucking tick toxin.

  Tick paralysis is a relatively rare and fatal disease caused by some blood-sucking species of female ticks from the Ixodidae family, especially Dermacentor andersoni and Ixodes scapularis. This disease, which is characterized by acute ascending flaccid paralysis, is usually misdiagnosed with other neurological diseases, especially Guillain-Barré syndrome, due to similar clinical manifestations [16].

• What is mass hysteria?

Mass hysteria or widespread hysteria (Epidemic Hysteria) is a manifestation of a conversion disorder that often occurs when people in a society are simultaneously under a stressor. This type of conversion disorder occurs in different clinical forms, including limb paralysis [12].

• Which of the symptoms in affected girls is not common in polio?

Paresthesia and sensory disturbance [12].

• What is Ross River fever?

Ross River fever is an epidemic polyarthritis that is transmitted by mosquitoes, and fever, fatigue, skin rashes, pain and swelling of the joints are symptoms of the disease and may last for several weeks to several months [17].

• What are Lyme disease and its characteristic sign?

Lyme disease is caused by a spirochete named Borrelia Burgdorferi. This bacterium is transmitted to humans through the bite of infected black-legged ticks. Typical symptoms include fever, headache, fatigue, and a characteristic skin rash called erythema migrants [18]. Skin rashes are a common symptom of Lyme disease. Cutaneous manifestations are usually seen as a single circle that slowly spreads from the tick bite site. It may be marked in the center and look like a target board or “Bull’s eye sign.” This characteristic rash is often warm to the touch but usually not painful or itchy [18].

9.2 Interpretation

• Immediately after confirming what were all of the affected girls visited by specialized teams? Why did not you choose other options?

  Because, at this stage, the various aspects of the case have not yet been clarified, the best word that is suggested for this situation is “health problem.” In explaining why, it is better not to use the other words, we refer to the specific definitions of the words given in the options below.

  The occurrence of more than the “expected limit” of a disease, an event, or special behavior, compared to the normal state, in the same region, same population, and in the same season of the year, is called an epidemic [19]. The records showed that there were no such situations in the region.

  The outbreak has the same definition as an epidemic, but it is often used for a limited geographic area and is more related to an infectious disease [19]. In this stage, it is not yet clear whether the cases are infectious or not.

  A disease is said to be endemic in a specific region or population, which is stable and continuous in that region [20], and this condition has occurred for the first time in the region and has not existed before.

  And finally, the expected accumulation of relatively uncommon events or diseases in an area is called a cluster. Cluster studies are usually used for non-infectious diseases such as cancers, spontaneous abortions, suicide, congenital anomalies, and so on. Cluster studies are also called Small Area Analyzes. The most common design for such studies is the case-control study [19].

• What diagnoses did the experts make for these patients and why?

  In the situation under discussion, due to the social tensions that were created during the mass vaccination of children under 5 years of age in society and familiesof affected girls, at first, experts should have considered the paralysis caused by the vaccination against polio.

  The other diagnoses were: Tick paralysis and Lyme disease, due to the incident in the village and the occupation of the families in animal husbandry, and the presence of some symptoms and mass hysteria due to the observation of certain contradictory behaviors in the patients.

• What were the reasons that these girls were not affected by polio?

  These reasons are given below:

  The reasons that did not confirm the existence of an organic communicable disease, especially polio among affected girls, were:

  Completeness of vaccination against poliomyelitis among most of the affected girls. The presence of paresthesia and sensory disturbances in girls’ responses to physicians, which are usually not the symptoms of polio. The contradiction of patients’ responses to different doctors. Absence of similar diseases among the community members, especially the family members of the patients. Lack of skin lesions that were contrary to insect bites, especially ticks, and not seeing ticks anywhere on the affected ’girls bodies. Absence of arthritis in the majority of the patients (among the patients, joint problems were mostly in the form of arthralgia, except in two cases who also had mild arthritis). The absence of a Bull’s-eye appearance on the skin is a characteristic sign of Lyme disease. Absence of fever, maculopapular rashes, and bilateral arthritis rules out Ross River Fever, and absence of signs of organic diseases, especially infectious diseases, in performed para-clinical tests [12].

• What are the reasons which confirm that these girls are suffering from mass hysteria?

  The points that confirmed the existence of collective hysteria were: the patients being female (mass hysteria is more common in females). This disorder is more common in the low to middle socioeconomic levels of society. And sufferers of this disorder are psychologically suggestible.

  The index case is the center of attention of her friends and other persons. She has an intellectual superiority over them and is a role model for them. This feature causes them to be assimilated. The dominant hand of all patients indicates a symbolic connection. As well as, the presence of stress caused by advertisements against polio disease and, at the same time, the stress of end-of-year exams is also an effective factor [20].

• Now that the diagnosis is known, which of the words, endemic, epidemic, outbreak, or cluster, do you choose for this phenomenon?

  By analyzing the conditions in the above definitions, we choose the word cluster [21].

• How to determine that the limb is not paralyzed?

  By carefully examining the reflexes of the affected upper limbs. If there is no paralysis, the reflexes are normal. (Normal mode detection).

9.3 Problem-solving

• What actions were taken for the patients?

  Psychotherapy - moving a paralyzed hand - giving nutritional supplements etc.

• What actions were taken for the patients with the recurrence of the disease?

  With the diagnosis of mass hysteria, a volleyball competition was organized among the students of several schools in the province, and the affected students were encouraged to participate. In these competitions, it was observed that the students used their hands well in different movement directions without any complaints.

10. Conclusion

We have innovated a new case-based method for self-study, self-assessment, practicing applied topics, and official evaluations of students. We have named this method TTT (Triple Taxonomy Test/technique) or MTQ (Mixed Taxonomy Questions). We hope that our audiences be familiar with this method and test their ability in reasoning, interpretation, and problem-solving.

It is suggested that the respected faculty members of different disciplines prepare a number of these cases from common diseases and use them for the students, according to their academic level (e.g., apprentices, interns, and residents). In our department, we have used this method by evaluating 20 parameters for medical students by designing 10 different cases, and the initial results indicate that the students are welcome; we are waiting to complete the number of samples.

Acknowledgments

We hereby consider it necessary to thank all the respected specialists who tried to diagnose these patients 30 years ago, as well as all the dear girls who are currently the mothers, brides and daughters of our country, and wish them the best for their health in all aspects.

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.